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Urinary Diversion and Augmentation

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Urinary Diversion and Augmentation Urinary Diversion and Augmentation Urinary Diversion and Augmentation 4 main types of urinary diversion: Ureterosigmoidostomy Mainz II Mansoura rectal bladder Ileal conduit Cutaneous continent urinary diversion Mainz I Kock pouch Indiana pouch Orthotopic urinary diversion Studer pouch Hautmann pouch 4 functional components of lower urinary tract: Non-refluxing Low pressure reservoir Continence mechanism Conduit to surface Type Reservoir Conduit Sphincter Ileal conduit - ileum - Mainz ureterosigmoidostomy sigmoid anal canal anal Indiana continent pouch caecum ileum iliocaecal valve Ileal neobladder ileum urethra rhabdosphincter Ileal conduit urinary diversion Originally described by Zaayer in 1911, popularised by Bricker in early 1950s Reliable, easily performed procedure which has stood test of time Typically 10-15 cm of ileum, 10-15cm from ileocaecal valve Uretero-ileal anastomosis: largest data from Bricker (7% stricture, 4% leak); lowest stricture and leak rate with Wallace Y technique (3% stricture, 2% leak) Contraindications: Short bowel syndrome Inflammatory bowel disease Pelvic irradiation Complications Early General (Infection, bleeding, DVT/PE) Specific (related to anastomoses) Urine leak Bowel leak Intestinal obstruction/prolonged ileus Stomal necrosis Stomal bleed Late General (problems with scar, incisional hernia) Specific Stomal complications 20% Tom Walton January 2011 1 Urinary Diversion and Augmentation Parastomal hernia Stomal stenosis Stomal retraction Conduit complications Stenosis Volvulus Excessive length Stone formation Upper tract dilatation* 30% (of which) Renal impairment 18% Dialysis dependence 7% Death from ESRF 6% Pyelonephritis (commonest acute complication) Renal deterioration** Stone formation Metabolic complications Previously thought to be over-reported Recent studies suggest 13-21% risk of metabolic complications Typically hyperchloraemic metabolic acidosis and low B12 Pyschological Lower reported QOL and sexual function vs. continent urinary diversion (Gerharz 1998) * Few studies performed analysing natural history and aetiology of renal unit deterioration. Important to differentiate patients with pre-diversion renal tract dilatation from those with normal units pre-surgery who subsequently develop dilatation. Good study by McNeal (1989) who compared urodynamics in patients with normal upper tracts and those with progressive dilatation after IC. High pressure high amplitude contractions predicted dilatation – half got better after revision of stoma ? due to stomal obstruction. Other causes of obstruction believed to be at uretero-ileal anastomosis, and the left ureter as it courses under the sigmoid mesentery. ** Renal deterioration usually a function of infection, stones or obstruction Reflux of infected urine particularly damaging, leading to renal dilatation, recurrent pyelonephritis, stone formation and scarring. Good animal evidence to suggest that non-refluxing uretero-ileal anastomoses may prevent upper tract deterioration, but not reproduced in adults: experiments with colonic conduits containing non-refluxing ureters a/w similar upper tract effects. Ureterosigmoidostomy Oldest form of clinically applied urinary diversion Early experience led to very high morbidity and mortality, particularly from obstruction and sepsis – improved somewhat by Leadbetter tunnelled anti- reflux anastomosis in early 1950’s However, very high intrarectal pressures (up to 200 cm water – Coffey 1911) led to persistent pyelonephritis and incontinence, and thus superseded by ileal conduit urinary diversion Tom Walton January 2011 2 Urinary Diversion and Augmentation Recent resurgence in interest stimulated by a number of modifications, designed to reduced intraluminal pressure (examples include Mansoura and Mainz II). A number of proponents believe this to be the diversion of choice in patients requiring a urethrectomy, particularly in developing countries as access to external appliances extremely limited. Mansoura rectal bladder Sigmoid intussusception to prevent reflux of urine into colon Ileal augmentation of sigmoid to reduce intraluminal pressure Ureters anastomosed to form a Kock nipple Mainz II Sigmoid opened longitudinally and closed transversely Tunnelled ureterosigmoid anastomosis Modified Mainz, incorporating ileal chimney Contraindications Poorly functioning anal sphincter (neuropathy, prolapse etc) Exclude with manometry or porridge test Pelvic radiotherapy Severe sigmoid diverticulosis Complications Early General Specific ~5% Urine leak Bowel leak Intestinal obstruction/prolonged ileus Late (Relatively scare long-term data for modified procedures) General Specific Hyperchloraemic acidosis ~50% of patients Uncorrected may lead to bone demineralisation and osteomalacia – difficult to spot on normal x-ray Usual presentation with acute metabolic acidosis due to intercurrent illness (severe thirst, N+V, salty taste in mouth, fatigue, rectal urge and diarrhoea) – treat with rectal catheter, sodium bicarbonate and IV hydration Nocturnal emptying mandatory to avoid severe acidosis Prophylaxis with 100-150 mmol/day sodium bicarbonate Ureterosigmoid cancers ~1500 x increased risk cf. general population Affects one third of long-term survivors > 20 yrs post-surgery 90% anastomotic 95% adenomatous Tom Walton January 2011 3 Urinary Diversion and Augmentation Faeces and urine admixture crucial for liberation of carcinogenic initiating chemicals (?N-nitroso compounds). Long lag-time – 18 yrs for benign tumour; 23 yrs for malignant tumour Renal deterioration Limited long-term data Similar results to IC urinary diversion Incontinence – very low Daytime >99% Night-time 97% Cutaneous continent urinary diversions Multiple differing procedures reported Many reliant on clean intermittent self catheterisation, popularised by Lapides (1972). All require a low pressure reservoir and continence mechanism Long-term results impaired by difficulties maintaining long-term continence mechanisms and conduit patency Subsequently superseded by orthotopic bladder substitution techniques, utilising rhabdosphincter and urethra. Thus, the use of a cutaneous continent urinary diversion tends to be reserved as a option for patients after urethrectomy. Examples: Kock pouch Ileal reservoir Intussuscepted ileal nipples - x1 to ureters, x 1 to skin to form catheterisable conduit Mainz I Caecum and ascending colon detubularised and closed Tunnelled ureters into wall of reservoir IC valve intusussepted into pouch Catheterisable ileal conduit Indiana Detubularised caecum IC valve forms continence mechanism Ileal catheterisable conduit Tom Walton January 2011 4 Urinary Diversion and Augmentation Contraindications to retentive diversion Renal impairment eGFR < 60ml/min Urine pH <5.8 after ammonium chloride loading test Osmolality < 600mosm/kg in response to water deprivation Hepatic impairment Bowel dysfunction Short bowel syndrome (<1.5m) Inflammatory bowel syndrome Previous pelvic radiotherapy Long-term chemotherapy*/disease modifying drugs (e.g. methotrexate) Psychiatric disorder Unable or unwilling to perform CISC Possibly age > 65 years (higher nocturnal eneuresis with orthotopics) * All patients undergoing short-term chemotherapy require pouch catheterisation beforehand to prevent toxicity Complications of retention diversion Infection Stone formation Particularly bad when staples are present in reservoir Upper tract dilatation Equivalent to ileal conduit As cutaneous continent diversions cannot leak anti-reflux mechanism mandatory to avoid upper tract dilatation. Less important with Studer pouch/chimney Renal impairment Reservoir rupture Severe complication Occurs in ~1% of cases (kids >>adults) Sudden onset of abdominal pain, peritonitis and reduced catheterisation volume (Treat with IVI, IVAbx and catheter, with recourse to laparotomy if fails to settle). Metabolic abnormalities Typically hyperchloreamic metabolic acidosis Malignancy True risk of malignancy in patients with bowel mucosa exposed to urine (without faeces) is unknown No malignant neoplasms in ileal conduits (adenomas occasionally) A small number of pouch neoplasias have been identified, a majority in patients with diversion for TB bladder. Interestingly most occurred around anastomosis, suggesting urothelium may be susceptible rather than enteric mucosa. High levels of nitrosamines identified in cystoplasties, particularly in those with positive urine cultures: ?bowel mucosa permissive for persistent infection, leading to bacterial conversion of urine, with subsequent initiation of cancer in urothelium. Tom Walton January 2011 5 Urinary Diversion and Augmentation Orthotopic bladder substitution Currently favoured bladder substitution method in those with retained functioning urethra and sphincter Originally pioneered by Camey and DeLuc in 1979 Many different reported technique, including Camey II, Hautmann W, Studer (see below), and orthotopic forms of Mainz and Kock. All obviates need for bag, neo-sphincter mechanism or catheterisable conduit Vast majority of patients dry, without requirement for ISC – usually empty bladder to completion by valsalva and relaxation of pelvic floor However well known that neobladders expand (up to seven fold) with time and requirement for ISC may develop in up to 30% after 5 yrs Similar complications to continent urinary diversions above Quality of life and urinary diversion Early studies showed no difference between IC and continent diversion for a number of parameters More recently widely believed that continent diversion is superior to IC in terms of sexual relationships self esteem and social interaction. However, no randomised controlled trial Two carefully performed reviews both concluded that there is insufficient evidence that one diversion better than another(Porter; Gerharz; both J Urol 2005) - emphasises requirement for careful patient counselling and selection prior to diversion Tom Walton January 2011 6 .
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